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Home My WebLink AboutApplication and WC � o� TOWN OF YARMOUTH BOARD OF HEALTH G3C�C�'C�OMCE oD ' �� APPLICATION FOR LICENSE/PERMI 0 �� , ,� �� . ` N04 10 2011 * Please complete form and attach all necess ` b fl�cembe IS 20I1. Failure to do so will result in the return " � o �p�pl cahon pac H DE�T. :� ESTABLISHMENTNAME: �t � � � � ' LOCATIONADDRESS: IH ��er�.� AvPr�lp TEL.#: �G� 55CnZ- �t'q�O MAILINGADDRESS: :�c��sc ��,�� ..-�.�e � Na4�„�.\�. -Tnl :��,��,�.1 OWNER NAME: 99 �Ne� T nc CORPORATION NAME (IF APPLICABLE): Qq iNP�.I , `�r� MANAGER'S NAME: USo�-Iec l�l1-, -�� TEL.#: MAII.ING ADDRESS: �xl�wr��! �r�rvri,.�r1h rMA C�2.toa%S POOL CERTIFTCATIONS: The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid i and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of ', employee certifications to this form. The Health Department will not use past years' records. You must I provide new copies and maintain a file at your place of business. ' 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is cer[if'ied as a Food Protection Manager, as defined in[he State Sanitary Code for Food Service Fstablishments, 105 CMR 590.000. Please attach copies of certif'ication to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment ' 1. 2. � PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. ; 1. 2. i HEIMLICH CERTIFTCATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich ' Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and � attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. �� 1. 2. ' 3. 4. ' RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I� _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $80ea �� _LODGE $55 _TTtnn.FRPARK $105 _WFIIRI,POOL $80ea � FOOD SERV[CE: ' LICENSE REQUIItED FEE PERMIT# LICE[VSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERMIT# '� `�0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 j 1,>100 SEATS $160 � "'b�� 1COMMON VIC. $60 ��a'��J _WHOLESALE $80 ; RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I. _<50 sq.fr. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 �� _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 � _TOBACCO $95 � NAME CHANGE: $15 AMOUNT DITE _ � v�w.��C% � � •*"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'�x•• I I � ADMINISTRATION • Under Chap[er 152,Section 25C,Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company dces not have a Certificate of Worker's Compensauon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED '� OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHII�NTS TRANSIENT OCCLJPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as de£med in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Departrnent prior to opening. Contact the Health Depamnent to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool azea until the pool has been inspected and opened. ' POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closutg. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: I All food service establishments must be inspected by the Health Department prior to opening. Please contact the I Health Department to schedule the inspection three(3) days prior to opening. CA1'ERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yazmouth Health Departrnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ', obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, ' Downloadable Forms. ' FROZEN DESSERTS: I Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results ' submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. II OUTSIDE CAFES: ' Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 15, 2011. AT,T. RENOVATIONS TO ANY FOOD ESTABI.ISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIIiE A STTE PLAN. DATE: t l�l� ��c+t� SIGNATURE: �11 � (� l PRINT NAME &TITLE: U�aLI� I/�(ho�-�-� �M Rev.IORS/11 , . �� • � The Commonwealth of Massachusetts Department of Industrial Accisdents O,�ce oflnvestigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance AftTidavit: General Businesses AppHcant Information Please Print Le¢iblv Business/Organization Name•99 West, Inc. dba 99 Restaurant&Pub Address: �4 BerryAvenue City/State/Zip: Yarmouth, MA 02673 Phone#: «8��2'�� Are you an employer? Check the appropriate boz: usiness Type(required): L� I am a employer with 79 employees(full and! 5. ❑Retail or part-time).' 6. �Restauca�tBazBating Fstablishment 2.❑ I am a sole proprietor or paztnership and 6ave no �, ❑Office and/or Sales(incl.real estate,auto,etc. employees working for me in any capaciry. 8. 0 Non-profit fNo workers'comp.insurance requiredJ 9. ❑Entertainment 3.❑ We are a corporahon and its officecs have exercise theu right of exemption per c. 152§ 1(4),and we have 10. ❑Manufactuting . no employeees. [No wokecs'comp. insurance required]• 11. �Health Care 4. ❑ We are a non-profit organization,staffed by volunteers, I2. �Other with no employees. [No workers'comp. insurauce req.] •MY aPUlic�t that chxks box#1 mut aiso fill wt the sa:fion below showing their workas'con�sation poticy infomretion r•ff tl�e coNo�te officas have eacempted�elves.brt tlr co�pwaba�has otF�rn�ployees,a workas'co�on poGcy is required and such� organization slauld check box#l. I am an employcr that is provrding workers'compensation insurance for my employees. Below is the policy injornration. Insurance Company Name: Zurich American Insurance Co., et al. Insurer's Address: �o Lockton Companies, 444 W. 47th St., Suite 900 Kansas Ci , MO 64112 � City/Sbte/Zip: tY Policy#or Self-ins.Lic.# W C9137280-04 Expiration Date: �15/2012 Attach a copy of the workers'compensatlon policy declaratlon page(showing the policy nnmber and eapiraHon dat F9ilure to secure covecage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year impriso�ent,as well as civil penalties in the form of a STOP WORK ORDER and a Sne of up to$250.00 a day against the violator. Be advised that a copy of this statement may be fornarded to the Office of Investigations of the DIA for+nc�,ran�coverage verificadon. I do hereby cereify,under the p and penalties ojpnjury that tke injormation provided above is due nn comct Sienature: �en '� �--_. Date• 11'�1�20�� Phone#: (8�5)2568500 � OJ)'icial use only. Do not write in this areq to be eompleted by eity or town oJJiciaL Yarmouth City or Town: Permit/Licenae# Issuing Authority(circle one) 1.Board of Health 2.BNlding Department 3.City/Town Clerk 4.Licenaing Board 5.Selectmen's Office 6.Offier Contact Person: Phone#: www.mass.aov �e